Materials 2015, 8, 4978-4991; doi:10.

3390/ma8084978
OPEN ACCESS

materials
ISSN 1996-1944
www.mdpi.com/journal/materials
Review

Zirconia as a Dental Biomaterial

Alvaro Della Bona *, Oscar E. Pecho and Rodrigo Alessandretti

Post-graduation Program in Dentistry, Dental School, University of Passo Fundo, Campus I,

BR285, Passo Fundo, RS 99052-900, Brazil; E-Mails: opey@correo.ugr.es (O.E.P.),
rodrigo.alle@yahoo.com.br (R.A.)

* Author to whom correspondence should be addressed; E-Mail: dbona@upf.br;

Tel.: +55-54-3316-8395; Fax: +55-54-3316-8409.

Academic Editor: Andrew J. Ruys

Received: 24 June 2015 / Accepted: 30 July 2015 / Published: 4 August 2015

Abstract: Ceramics are very important in the science of dental biomaterials. Among all
dental ceramics, zirconia is in evidence as a dental biomaterial and it is the material of choice
in contemporary restorative dentistry. Zirconia has been applied as structural material for
dental bridges, crowns, inserts, and implants, mostly because of its biocompatibility, high
fracture toughness, and radiopacity. However, the clinical success of restorative dentistry
has to consider the adhesion to different substrates, which has offered a great challenge to
dental zirconia research and development. This study characterizes zirconia as a dental
biomaterial, presenting the current consensus and challenges to its dental applications.

Keywords: biomaterials; zirconia; bonding

1. Characteristics of Zirconia

The most popular dental ceramic systems are silica-, leucite-, lithium disilicate-, alumina-, and
zirconia-based materials. Currently, zirconia-based ceramics are the most studied, challenging researches
for different reasons.
Zirconia (zirconium dioxide, ZrO2), also named as “ceramic steel”, has optimum properties for
dental use: superior toughness, strength, and fatigue resistance, in addition to excellent wear properties
and biocompatibility.
Materials 2015, 8 4979

Zirconium (Zr) is a very strong metal with similar chemical and physical properties to titanium (Ti).
Incidentally, Zr and Ti are two metals commonly used in implant dentistry, mostly because they do not
inhibit the bone forming cells (osteoblasts), which are essential for osseointegration [1].
Dental zirconia is, most often, a modified yttria (Y2O3) tetragonal zirconia polycrystal (Y-TZP).
Yttria is added to stabilize the crystal structure transformation during firing at an elevated temperature
and improve the physical properties of zirconia. Upon heating, the monoclinic phase of zirconia starts
transforming to the tetragonal phase at 1187 °C, peaks at 1197 °C, and finishes at 1206 °C. On cooling,
the transformation from the tetragonal to the monoclinic phase starts at 1052 °C, peaks at 1048 °C, and
finishes at 1020 °C, exhibiting a hysteresis behavior. The zirconia tetragonal-to-monoclinic phase
transformation is known to be a martensitic transformation [2]. During this zirconia phase
transformation, the unit cell of monoclinic configuration occupies about 4% more volume than the
tetragonal configuration, which is a relatively large volume change. This could result in the formation
of ceramic cracks if no stabilizing oxides were used. Ceria (CeO2), yttria (Y2O3), alumina (Al2O3),
magnesia (MgO) and calcia (CaO) have been used as stabilizing oxides. So, as the monoclinic phase
does not form under normal cooling conditions, the cubic and tetragonal phases are retained, and crack
formation, due to phase transformation, is avoided [2]. It is also important to consider that the
stabilization of the tetragonal and cubic structures requires different amounts of dopants (stabilizers).
The tetragonal phase is stabilized at lower dopant concentrations than the cubic phase. However, another
way of stabilizing the tetragonal phase at room temperature is to decrease the crystal size (the critical
average grain size is <0.3 μm) [3]. This effect has been attributed to a surface energy difference [2].
Consequently, zirconia-based ceramics used for biomedical purposes typically exist as a metastable
tetragonal partially stabilized zirconia (PSZ) at room temperature. Metastable means that trapped energy
still exists within the material to drive it back to the monoclinic phase. It turned out that the highly
localized stress ahead of a propagating crack is sufficient to trigger zirconia grains to transform in the
vicinity of the crack tip. In this case, the 4% volume increase becomes beneficial, essentially squeezing
the crack to close and increasing toughness, known as transformation toughening [2].

2. Zirconia Structures for Dentistry

Zirconia structures used for dental purposes are fabricated using CAD-CAM (computer-aided design
and computer-aided manufacturing) technology in two possible ways. One method mills the fully
sintered block of zirconia with no distortion (shrinkage) to the final structure. The disadvantages are the
great wear of the grinding tools (burs) and the population of flaws produced during the machining that
may lower the mechanical reliability of the structure [4,5]. In the other method, the zirconia structure is
milled from a pre-sintered block, reaching its final mechanical properties after sintered, which produces
structural shrinkage that can be partly compensated at the designing stage, and the fit of the zirconia
restoration will be warranted [6,7]. Both CAD-CAM processes have three main steps: acquisition of
digital data, computer processing and designing, and fabrication of the zirconia structure [8].
Most importantly, the CAD-CAM technique has the ability to produce zirconia restorations with
sufficient precision for dental use [9,10].
Traditionally, zirconia is dull white in color and its opacity can mask the underneath structure.
Most dental zirconia systems indicate structural dyeing (coloring) to enhance the esthetic [11]. Currently,
Materials 2015, 8 4980

full-contoured (anatomical-shaped) monolithic zirconia dental restorations are offered [12,13], which
could abbreviate or extinguish the dental laboratory work on zirconia-based restorations. Several studies
reported, however, that Y-TZP would lose its stability in wet environment, leading to strength
degradation mostly because of the crystallographic transformation from metastable tetragonal phase to
monoclinic phase (T-M transformation) and inherent cyclic fatigue from chewing and para-functional
habits (e.g., bruxism and clenching) [2,6,7,14,15]. Nevertheless, the influence of low temperature
degradation (LTD) on dental zirconia is still in need of further investigation.
Even so, the most popular zirconia-based restorations have a zirconia infrastructure that is porcelain
veneered to adequate anatomic contour and esthetic. There are two main ways of veneering zirconia
infrastructures: the traditional layering technique and the hot pressing method [2,7]. Both methods
require some sort of porcelain to zirconia bonding. Some studies have observed an exchange of certain
chemical elements at the porcelain-zirconia interface, which may contribute to bonding [7,16], but
whether a true chemical bonding has formed is yet to be verified. Therefore, micro-or nano-mechanical
interlocking is regarded as the major mechanism of porcelain zirconia bonding [17]. On this basis, and
with some dispute, sandblasting the zirconia surface before porcelain veneering or resin bonding appears
to be the most popular method to promote mechanical interlocking and most reports recommend
moderate pressure (around 0.4 MPa) and small particle size [18,19]. Other studies suggest that sandblasting
induces monoclinic phase transformation, but it can be reversed by the veneering process [7,20,21].
In addition, primers and liners have been suggested to improve wetting and bonding to zirconia [2,19,22,23].
Nonetheless, one of the most important reasons for introducing monolithic zirconia restorations is the
significant rate of porcelain fracture from porcelain veneered zirconia-based restorations (6%–25% after
three years), which is greater than the fracture rate reported for porcelain fused-to-metal (PFM)
systems [2,24–29]. This subject challenged many researchers and triggered few review publications on
the fracture rate of all-ceramic restorations [24,27,30], indicating that delamination (failure at
porcelain-zirconia interface) and chipping (failure within the veneering porcelain) are the most common
modes of failure [30,31]. Studies suggested several possible causes for porcelain failure on
zirconia-based restorations [7,15,22,32–36].
The mismatch in some mechanical and thermal properties such as fracture toughness, flexural
strength, coefficient of thermal expansion, and elastic modulus affect the bonding between porcelain and
zirconia [7,34–38]. One study emphasized the effect of strength misfit on the development of
delamination, showing that the mode of failure changes according to the porcelain strength and
suggesting the use of veneering material with a high flexural strength (over 300 MPa) to improve the
reliability of zirconia-based restorations [32].
Significant differences on the coefficient of thermal expansion between the zirconia and porcelain
influence in the residual stress distribution during the cooling process affecting the reliability of
zirconia-based restorations [7,15,22,33–35,38–40]. The veneering porcelain will experience a change
from a viscoelastic state to a solid form when its temperature is reduced and when it passes through the
glass transition temperature (Tg from 480 °C to 610 °C) [2,7,40]. During cooling after sintering, residual
stresses might be generated and influence both the strength of porcelain and interfacial integration.
Therefore, most manufacturers recommend slow cooling processes [2,38,39].
The initiation and propagation of delamination was also reported to be related to the misfit in elastic
moduli and fracture toughness of porcelain and zirconia [36].
Materials 2015, 8 4981

Pressable veneering porcelains were thought to improve bonding between porcelain and zirconia, but
studies are controversial on this matter and most of them showed no significant difference between the
traditional and pressing methods [41,42]. New veneering methods using CAD-CAM technology seem
to improve wetting and bond strength between zirconia and porcelain [43,44].

3. Resin Bonding to Zirconia

At first, one could imagine that an all-ceramic restoration would not withstand the intra-oral service.
It could be true if the restoration would not be bonded to the tooth structure or remaining restorative
materials (e.g., composites and metals), working as an integrated system where diverse stresses,
from chewing to para-functional habits (e.g., bruxism), are distributed throughout the system due to
appropriate bonding [2,45]. This rationale is supported by the ISO 6872:2010 [46] standard that classifies
the ceramics according to the intended clinical use and made the distinction between adhesively and
non-adhesively cemented restorations.
Today, glass ionomer (GIC) and resin-based cements are the primary choices for bonding ceramic
restorations to the remaining tooth structure. GIC and resin-modified GIC (RMGIC) are often used to
cement acid-resistant ceramics, mostly because these cements are very easy to use. However, the most
popular and effective cements for all types of ceramic restorations are the resin-based composites, including
the systems containing the 10-methacryloyloxydecyl-dihydrogen-phosphate (MDP) monomer [2,45,47].
It has been reported that the clinical success of resin bonding procedures for cementing ceramic
restorations and repairing fractured ceramic restorations depends on the quality and durability of the
bond. The former depends upon the bonding mechanisms that are controlled in part by the surface
treatment that promotes micromechanical and/or chemical bond to the substrate [6,48–58].
The nonreactive surface of zirconia (acid-resistant ceramic), however, presents a consistent issue of poor
adhesion, i.e., low bond strength to other substrates [2].
As zirconia is an acid-resistance ceramic, other methods to produce micromechanical retention have
been used, including airborne particle abrasion (APA) systems, often called sandblasting, and coarse
diamond rotary instruments. Several studies [17,45,47,50,51,58,59] reported that airborne particle abrasion
methods using alumina particles or silica-modified alumina particles (silica coating) produced greater
surface roughness (Ra) values and that silica coated surfaces showed a significant increase (76%) in the
concentration of silicon, which should enhance bonding to resin via silane coupling agents [45,51,59].
Therefore, silica coating (silicatization) systems (e.g., Rocatec and Cojet, 3M-ESPE) have been used to
create a silica layer on metal and ceramic surfaces through high-speed surface impact of the silica-modified
alumina particles that can penetrate up to 15 m into ceramic and metal substrates. This tribochemical
effect may be explained by two bonding mechanisms: (1) the creation of a topographic pattern via airborne
particle abrasion allowing for micromechanical bonding to resin; and (2) the promotion of a chemical bond
between the silica coated ceramic surface and the resin-based material, via a silane coupling agent [2,45].
Therefore, the adhesion between dental ceramics and resin-based composites is the result of a
physico-chemical interaction across the interface between the resin (adhesive) and the ceramic
(substrate). The physical contribution to the adhesion process is dependent on the surface treatment and
topography of the substrate and can be characterized by its surface energy. Alteration of the surface
topography results in changes on the surface area and on the wettability of the substrate, which are related
Materials 2015, 8 4982

to the surface energy and the adhesive potential. In addition, the surface energy of a solid surface is
greater than that of its interior where the interatomic distances are equal, and the energy is minimal. In
fact, at the surface of the lattice, the energy is greater because the outermost atoms are not equally
attracted in all directions. This increase in energy per unit area of surface (J/m2 or N/m) is referred to as
the surface energy (), or surface tension for liquids (e.g., water:  = 73 mJ/m2;
PTFE- polytetrafluoroethylene:  = 18 mJ/m2; steel:  = 230 mJ/m2; liquid resin:  = 40 mJ/m2) [2,45].
Therefore, the surface atoms of a solid tend to form bonds to other atoms in close proximity to the
surface, reducing the surface energy of the solid. Achieving an energy balance or the lowest energy state
is the driving force for the chemical bond between the adhesive and the adherend. However, the surface
energy and the adhesive qualities of a given solid can be reduced by any surface impurity or contaminant,
such as human secretions and air voids. The functional chemical groups available or the type of crystal
plane of a space lattice present at the surface also affect the surface energy [2,45].
Nevertheless, a clean (no contaminants) and dry surface ensures that the adhesive has the best possible
chance of creating a proper bond with the adherend. In addition, the wettability of the adherend by the
adhesive, the viscosity of the adhesive, and the morphology of adherend surface influence the ability of
the adhesive to make intimate contact with the adherend. Thus, to succeed the challenge of resin-bonding
to zirconia-based ceramics, one must consider all aspects listed above [2,45]. This rationale has been
followed, somehow, in the reports on bonding to zirconia (Table 1). Most experimental procedures that
resulted in high bond strength values and had clinical feasibility were tried in vivo. Clinical trials on
veneered zirconia-based restorations have showed survival rates of 75%–100% [28,29,60,61], which are
similar to other successful restorative procedures.

Table 1. Experimental studies, in chronological order, on resin bonded dental zirconia.

Aging Mean Bond
Test Suggested Bonding
Study Dental Zirconia (Y, yes; Strength
Method Treatment
N, no) (MPa)
Janda et al., Flame-treated for 5 s/cm2
Frialit (Degussit) Y shear 16 ±6
2003 [62] (PyrosilPen) + silane
Blatz et al., Procera AllZirkon APA + adhesive with
Y shear 16.8 ±3.7
2004 [63] (Nobel Biocare) MDP + Panavia F
Piwowarczyk
Lava (3M-Espe) Y shear Silicatization (Rocatec) 19.9 ±2.6
et al., 2005 [64]
Derand et al., Procera Zirkon Low fusing porcelain
N shear 18.4 ±3.6
2005 [23] (Nobel Biocare) pearls + silane
Atsu et al., APA + silicatization (Cojet) +
Cercon (Dentsply) N shear 22.9 ±3.1
2006 [65] adhesive with MDP + Panavia F
Lüthy et al., Silicatization (Rocatec) +
Cercon (Dentsply) Y shear 73.8 ±8.5
2006 [66] Panavia 21
Kumbuloglu APA + Silicatization (Rocatec)
DCS (Dental AG) Y shear 20.9 ±4.6
et al., 2006 [67] + Panavia F
Blatz et al., Silicatization (Rocatec) +
Lava (3M-Espe) Y shear 16.6 ±3.2
2007 [68] Panavia F
Wolfart et al.,
Cercon (Dentsply) Y tensile APA + Panavia F 39.2
2007 [69]
Materials 2015, 8 4983

Table 1. Cont.
Aging Mean Bond
Test Suggested Bonding
Study Dental Zirconia (Y, yes; Strength
Method Treatment
N, no) (MPa)
Aboushelib APA + infiltration
Cercon (Dentsply) N microtensile 49.8 ±2.7
et al., 2007 [70] etching + Panavia F2.0
Yang et al.,
Cercon (Dentsply) Y tensile APA + Panavia F2.0 29.6 ±4.8
2008 [71]
Aboushelib Procera Zirconia infiltration etching + silane
N microtensile 40.6 ±5.8
et al., 2008 [72] (Nobel Biocare) primer + Panavia F2.0
Piascik et al., e.max ZirCad APA + Sí lica seed
N microtensile 23.2 ±5.4
2009 [73] (Ivoclar) layer + silane + C&B
Cavalcanti APA + metal primer +
Cercon (Dentsply) N microshear 27.9 ±4.5
et al., 2009 [74] BisGMA resin cement
Heikkinen Procera Zirconia Silicatization (Rocatec) +
Y shear 4.7 ±2.7
et al., 2009 [75] (Nobel Biocare) silane + resin cement
Aboushelib et Procera Zirconia infiltration etching + silane
N microtensile 41.0 ±5.8
al., 2009 [76] (Nobel Biocare) primer + Panavia F2.0
Oyagüe et al., Silicatization + resin cement
Cercon (Dentsply) N microtensile 15.3 ±3.3
2009 [77] with MDP
Kitayama et al.,
Cercon (Dentsply) N tensile APA + AZ primer + Resicem 22.3 ±4.6
2010 [78]
Magne et al.,
Lava (3M-Espe) N shear APA + primer + Duo-Link 26.6 ±6.2
2010 [79]
Qeblawi et al., e.max ZirCad silicatization + silane +
Y shear 30.9 ±4.6
2010 [80] (Ivoclar) Multilink
Jevnikar et al., TZ-3YB-E APA + alumina coating +
Y shear 27.3 ±3.9
2010 [81] Zirconia (Tosoh) resin cement
Attia et al., e.max ZirCad Silicatization (Rocatec) +
Y tensile 39.7 ±7.0
2011 [82] (Ivoclar) silane + Multilink
Matinlinna and
Procera All Zircon Silicatization (Rocatec) +
Lassila, Y shear 11.7 ±2.3
(Nobel Biocare) silane + resin cement
2011 [83]
Dias de Souza Lava Frame APA + adhesive with MDP +
N microtensile 6.1 ±5.3
et al., 2011 [84] (3M-Espe) resin cement
de Castro et al., In-Ceram YZ Silicatization (Cojet) + silane +
Y microtensile 13.9 ±6.0
2012 [85] (Vita) resin cement
Lung et al., Silicatization (Rocatec) +
Lava (3M-Espe) Y shear 14.5 ±2.2
2012 [86] silane + resin cement
Piascik et al., Plasma fluorination + resin
Lava (3M-Espe) N shear 37.3 ±4.6
2012 [87] cement
Chen et al., APA + primer with MDP +
Cercon (Dentsply) N shear 29.0 ±6.3
2013 [88] resin cement
Karimipour-
TZP BIO-HIP
Saryazdi et al., Y tensile APA + resin cement 3.7 ±1.0
(Metoxit AG)
2014 [89]
Materials 2015, 8 4984

Table 1. Cont.
Aging Mean Bond
Test Suggested Bonding
Study Dental Zirconia (Y, yes; Strength
Method Treatment
N, no) (MPa)
Bavbek et al., BruxZir and Silicatization (Cojet) + silane +
N microshear 45.9 ±4.8
2014 [90] Prettau-Zirkon resin cement
da Silva et al., Lava Frame Silicatization (Cojet) + silane +
N microshear 37.4 ±2.3
2014 [91] (3M-Espe) resin cement
Oba et al., YPS (Kuraray Silane with MDP (Monobond
Y shear 7.7 ±2.9
2014 [92] Noritake) Plus) + resin cement
Pereira et al., APA + primer with MDP +
Lava (3M-Espe) N shear 14.1 ±6.1
2015 [93] resin cement
Şanlı et al., In-Ceram YZ
N flexural APA + resin cement 50.5 ±1.3
2015 [94] (Vita)
Kim et al., KZ-3YF AC
N shear Zirconia primer + resin cement 10.8 ±1.5
2015a [95] (KCM)
Abi-Rached
Lava (3M-Espe) N shear APA + resin cement 7.7 ±1.1
et al., 2015 [96]
Oliveira-
Zircon-CAD Silica coating + silane +
Ogliari et al., N shear 36.7 ±6.3
(Angelus) resin cement
2015 [97]
Lung et al., Silicatization (Rocatec) +
Upcera (Liaoning) Y shear 12.6 ±2.2
2015 [98] silane + resin cement
Sciasci et al., Silicatization (Rocatec) +
Lava (3M-Espe) N shear 14.9 ±3.0
2015 [99] silane + resin cement
Qeblawi et al., Silicatization (Cojet) + silane +
DiaZir (Wieland) Y shear 25.6 ±2.9
2015 [100] resin cement
Yi et al., 2015 APA + Z-prime Plus +
Lava (3M-Espe) Y shear 16.5 ±2.2
[101] self-adhesive resin cement
Kim et al., Cercon Base Adhesive with MDP +
Y microshear 26.9 ±6.4
2015b [102] (Dentsply) resin cement
Druck et al., In-Ceram YZ Silicatization + silane +
Y shear 9.1 ±4.4
2015 [103] (Vita) resin cement
APA-Airborne particle abrasion (sandblasting); water storage was not considered as an aging process.

Considering the in vitro studies (Table 1) and the clinical trials, the two most popular clinical
strategies to resin bond acid-resistant ceramic restorations are [2,45]:
1. Improving mechanical retention with APA using alumina particles associated to a chemical
bonding mechanism using an adhesive/cement system containing ceramic primers, such as
phosphate-based monomers, e.g., MDP.
2. Improving mechanical retention with APA using silica-coated alumina particles to introduce
an irregular silica layer onto the ceramic surface followed by a silane coupling agent,
which promotes a chemical bond to any resin-based adhesive/cement system.
Nevertheless, manufacturers routinely provide cementation recommendations that should be given
serious consideration.
Materials 2015, 8 4985

However, dental ceramics are, inherently, brittle and can fracture. In general, the most common
causes of all-ceramic structural failures are (1) fracture initiated in the connector area of fixed partial
dentures (FPDs), either at the core-veneer interface or at the gingival embrasure; and (2) chipping of the
porcelain veneer [2,6,24,38,60,104–107].
The mode of failure is an important aspect of bond strength tests, but it is not commonly reported.
A detailed inspection of the fractured surfaces can indicate the failure mode of a bonded assembly.
The fracture behavior of adhesive interfaces depends on the stress level, the flaw distribution, material
properties, and environmental effects. Therefore, fracture surface characterization combined with
analyses of fracture mechanics parameters are of great importance to understand and predict bonded
interface reliability and also to reduce the risk for data misinterpretation such as the inference that the
bond strength exceed the cohesive strength of the substrate when the fracture initiates away from the
interface [2,45,47,51,55]. Therefore, failure analysis based on fractographic principles should assist
researchers to correctly interpret the fracture phenomena [2,45,47,55,108–111], avoiding simplistic
comments such as “mixed mode of failure”. Thus, when fractography is correctly used to determine the
fracture origin, a proper scientific statement on the mode of fracture can be formulated, improving the
quality of the scientific report [2].
The above rationale on adhesion to zirconia should develop the fundamental basis to understand the
clinical performance of bonded zirconia-based restorations, the possible failure causes, and the principles
to improve the adhesion mechanisms of resin-based composite bonded to zirconia.

Acknowledgments

This study was partially supported by CNPq do Brasil grant # 304995/2013-4, PNPD 42009014007P4
from CAPES (Coordenação de Aperfeiçoamento de Pessoal de Ní vel Superior) do Brasil, and 396-2551/14-1
from FAPERGS (Fundação de Amparo àPesquisa do Estado do Rio Grande do Sul) scholarships.

Author Contributions

The first author is the main author. The article was written and edited by Alvaro Della Bona,
Oscar E. Pecho and Rodrigo Alessandretti.

Conflicts of Interest

The authors declare no conflict of interest

References

1. Kobayashi, E.; Matsumoto, S.; Doi, H.; Yoneyama, T.; Hamanaka, H. Mechanical properties of
the binary titanium-zirconium alloys and their potential for biomedical materials. J. Biomed.
Mater. Res. 1995, 29, 943–950.
2. Della Bona, A. Bonding to Ceramics: Scientific Evidences for Clinical Dentistry; Artes Medicas:
Sao Paulo, Brazil, 2009.
3. Becher, P.F.; Swain, M.V. Grain-size-dependent transformation behavior in polycrystalline
tetragonal zirconia. J. Am. Ceram. Soc. 1992, 75, 493–502.
Materials 2015, 8 4986

4. Luthardt, R.G.; Holzhüter, M.; Sandkuhl, O.; Herold, V.; Schnapp, J.D.; Kuhlisch, E.; Walter, M.
Reliability and properties of ground Y-TZP-zirconia ceramics. J. Dent. Res. 2002, 81, 487–491.
5. Corazza, P.H.; de Castro, H.L.; Feitosa, S.A.; Kimpara, E.T.; Della Bona, A. Influence of
CAD-CAM diamond bur deterioration on surface roughness and maximum failure load of
Y-TZP-based restorations. Am. J. Dent. 2015, 28, 95–99.
6. Denry, I.; Kelly, J.R. State of the art of zirconia for dental applications. Dent. Mater. 2008, 24,
299–307.
7. Liu, D.; Matinlinna, J.P.; Pow, E.H.N. Insights into porcelain zirconia bonding. J. Adhes. Sci. Technol.
2012, 26, 1249–1265.
8. Coli, P.; Karlsson, S. Precision of a CAD/CAM technique for the production of zirconium dioxide
copings. Int. J. Prosthodont. 2004, 17, 577–580.
9. Abduo, J.; Lyons, K.; Swain, M. Fit of zirconia fixed partial denture: A systematic review. J. Oral
Rehabil. 2010, 37, 866–876.
10. Boitelle, P.; Mawussi, B.; Tapie, L.; Fromentin, O. A systematic review of CAD/CAM fit
restoration evaluations. J. Oral Rehabil. 2014, 41, 853–874.
11. Hjerppe, J.; Närhi, T.; Fröberg, K.; Vallittu, P.K.; Lassila, L.V. Effect of shading the zirconia
framework on biaxial strength and surface microhardness. Acta Odontol. Scand. 2008, 66, 262–267.
12. Batson, E.R.; Cooper, L.F.; Duqum, I.; Mendonça, G. Clinical outcomes of three different crown
systems with CAD/CAM technology. J. Prosthet. Dent. 2014, 112, 770–777.
13. Sun, T.; Zhou, S.; Lai, R.; Liu, R.; Ma, S.; Zhou, Z.; Longquan, S. Load-bearing capacity and the
recommended thickness of dental monolithic zirconia single crowns. J. Mech. Behav. Biomed. Mater.
2014, 35, 93–101.
14. Piconi, C.; Maccauro, G. Zirconia as a ceramic biomaterial. Biomaterials 1999, 20, 1–25.
15. Swain, M.V. Unstable cracking (chipping) of veneering porcelain on all-ceramic dental crowns
and fixed partial dentures. Acta Biomater. 2009, 5, 1668–1677.
16. Kawai, Y.; Uo, M.; Watari, F. Microstructure evaluation of the interface between dental zirconia
ceramics and veneering porcelain. Nano Biomed. 2010, 2, 31–36.
17. Queiroz, J.R.; Benetti, P.; Massi, M.; Junior, L.N.; Della Bona, A. Effect of multiple firing and
silica deposition on the zirconia-porcelain interfacial bond strength. Dent. Mater. 2012, 28,
763–768.
18. Nakamura, T.; Wakabayashi, K.; Zaima, C.; Nishida, H.; Kinuta, S.; Yatani, H. Tensile bond
strength between tooth-colored porcelain and sandblasted zirconia framework. J. Prosthodont. Res.
2009, 53, 116–119.
19. Kern, M. Bonding to oxide ceramics—laboratory testing versus clinical outcome. Dent. Mater.
2015, 31, 8–14.
20. Guazzato, M.; Quach, L.; Albakry, M.; Swain, M.V. Influence of surface and heat treatments on
the flexural strength of Y-TZP dental ceramic. J. Dent. 2005, 33, 9–18.
21. De Kler, M.; de Jager, N.; Meegdes, M.; van der Zel, J.M. Influence of thermal expansion
mismatch and fatigue loading on phase changes in porcelain veneered Y-TZP zirconia discs.
J. Oral Rehabil. 2007, 34, 841–847.
22. Aboushelib, M.N.; de Jager, N.; Kleverlaan, C.J.; Feilzer, A.J. Microtensile bond strength of
different components of core veneered all-ceramic restorations. Dent. Mater. 2005, 21, 984–991.
Materials 2015, 8 4987

23. Derand, T.; Molin, M.; Kvam, K. Bond strength of composite luting cement to zirconia ceramic
surfaces. Dent. Mater. 2005, 21, 1158–1162.
24. Della Bona, A.; Kelly, J.R. The clinical success of all-ceramic restorations. J. Am. Dent. Assoc.
2008, 139, S8–S13.
25. Della Bona, A.; Kelly, J.R. A variety of patient factors may influence porcelain veneer survival
over a 10-year period. J. Evid. Based Dent. Pract. 2010, 10, 35–36.
26. Vult von Steyern, P.; Carlson, P.; Nilner, K. All-ceramic fixed partial dentures designed according
to the DC-Zirkon technique. A 2-year clinical study. J. Oral Rehabil. 2005, 32, 180–187.
27. Sailer, I.; Pjetursson, B.E.; Zwahlen, M.; Hämmerle, C.H. A systematic review of the survival and
complication rates of all-ceramic and metal-ceramic reconstructions after an observation period of
at least 3 years. Part II: Fixed dental prostheses. Clin. Oral Implants Res. 2007, 18, 86–96.
28. Tinschert, J.; Schulze, K.A.; Natt, G.; Latzke, P.; Heussen, N.; Spiekermann, H. Clinical behavior
of zirconia-based fixed partial dentures made of DC-Zirkon: 3-year results. Int. J. Prosthodont.
2008, 21, 217–222.
29. Sailer, I.; Gottnerb, J.; Kanelb, S.; Hammerle, C.H. Randomized controlled clinical trial of
zirconia-ceramic and metal-ceramic posterior fixed dental prostheses: A 3-year follow-up. Int. J.
Prosthodont. 2009, 22, 553–560.
30. Al-Amleh, B.; Lyons, K.; Swain, M. Clinical trials in zirconia: A systematic review. J. Oral
Rehabil. 2010, 37, 641–652.
31. Deng, Y.; Lawn, B.R.; Lloyd, I.K. Characterization of damage modes in dental ceramic bilayer
structures. J. Biomed. Mater. Res. 2002, 63, 137–145.
32. Liu, Y.; Feng, H.; Bao, Y.; Qiu, Y.; Xing, N.; Shen, Z. Fracture and interfacial delamination origins
of bilayered ceramic composites for dental restorations. J. Eur. Ceram. Soc. 2010, 30, 1297–1305.
33. Saito, A.; Komine, F.; Blatz, M.B.; Matsumura, H. A comparison of bond strength of layered
veneering porcelains to zirconia and metal. J. Prosthet. Dent. 2010, 104, 247–257.
34. Aboushelib, M.N.; Feilzer, A.J.; de Jager, N.; Kleverlaan, C.J. Prestresses in bilayered all-ceramic
restorations. J. Biomed. Mater. Res. B Appl. Biomater. 2008, 87, 139–145.
35. Fischer, J.; Stawarzcyk, B.; Trottmann, A.; Hämmerle, C.H. Impact of thermal misfit on shear
strength of veneering ceramic/zirconia composites. Dent. Mater. 2009, 25, 419–423.
36. Guazzato, M.; Proos, K.; Quach, L.; Swain, M.V. Strength, reliability and mode of fracture of
bilayered porcelain/zirconia (Y-TZP) dental ceramics. Biomaterials 2004, 25, 5045–5052.
37. Aboushelib, M.N.; Kleverlaan, C.J.; Feilzer, A.J. Effect of zirconia type on its bond strength with
different veneer ceramics. J. Prosthodont. 2008, 17, 401–408.
38. Benetti, P.; Della Bona, A.; Kelly, J.R. Evaluation of thermal compatibility between core and
veneer dental ceramics using shear bond strength test and contact angle measurement. Dent. Mater.
2010, 26, 743–750.
39. Taskonak, B.; Mecholsky, J.J.; Anusavice, K.J. Residual stresses in bilayer dental ceramics.
Biomaterials 2005, 26, 3235–3241.
40. Taskonak, B.; Borges, G.A.; Mecholsky, J.J.; Anusavice, K.J.; Moore, B.K.; Yan, J. The effects of
viscoelastic parameters on residual stress development in a zirconia/glass bilayer dental ceramic.
Dent. Mater. 2008, 24, 1149–1155.
Materials 2015, 8 4988

41. Guess, P.C.; Zhang, Y.; Thompson, V.P. Effect of veneering techniques on damage and reliability
of Y-TZP trilayers. Eur. J. Esthet. Dent. 2009, 4, 262–276.
42. Aboushelib, M.N.; Kleverlaan, C.J.; Feilzer, A.J. Microtensile bond strength of different
components of core veneered all-ceramic restorations. Part 3: Double veneer technique.
J. Prosthodont. 2008, 17, 9–13.
43. Aboushelib, M.N.; de Kler, M.; van der Zel, J.M.; Feilzer, A.J. Effect of veneering method on the
fracture and bond strength of bilayered zirconia restorations. Int. J. Prosthodont. 2008, 21, 237–240.
44. Renda, J.J.; Harding, A.B.; Bailey, C.W.; Guillory, V.L.; Vandewalle, K.S. Microtensile bond
strength of lithium disilicate to zirconia with the CAD-on technique. J. Prosthodont. 2015, 24,
188–193.
45. Della Bona, A.; Borba, M.; Benetti, P.; Pecho, O.E.; Alessandretti, R.; Mosele, J.C.; Mores, R.T.
Adhesion to dental ceramics. Curr. Oral Health Rep. 2014, 1, 232–238.
46. ISO 6872:2010 Dental Ceramics, 3rd ed.; International Organization of Standardization (ISO):
Geneva, Switzerland, 2010.
47. Della Bona, A. Important aspects of bonding resin to dental ceramics. J. Adhes. Sci. Technol. 2009,
23, 1163–1176.
48. Della Bona, A.; Anusavice, K.J. Microstructure, composition, and etching topography of dental
ceramics. Int. J. Prosthodont. 2002, 15, 159–167.
49. Della Bona, A.; Anusavice, K.J.; Hood, J.A. Effect of ceramic surface treatment on tensile bond
strength to a resin cement. Int. J. Prosthodont. 2002, 15, 248–253.
50. Della Bona, A.; Donassollo, T.A.; Demarco, F.F.; Barrett, A.A.; Mecholsky, J.J. Characterization
and surface treatment effects on topography of a glass-infiltrated alumina/zirconia-reinforced
ceramic. Dent. Mater. 2007, 23, 769–775.
51. Della Bona, A.; Borba, M.; Benetti, P.; Cecchetti, D. Effect of surface treatments on the bond
strength of a zirconia-reinforced ceramic to composite resin. Braz. Oral. Res. 2007, 21, 10–15.
52. Van Noort, R.; Noroozi, S.; Howard, I.C.; Cardew, G. A critique of bond strength measurements.
J. Dent. 1989, 17, 61–67.
53. Boscato, N.; Della Bona, A.; Del Bel Cury, A.A. Influence of ceramic pre-treatments on tensile
bond strength and mode of failure of resin bonded to ceramics. Am. J. Dent. 2007, 20, 103–108.
54. Della Bona, A.; van Noort, R. Shear vs. tensile bond strength of resin composite bonded to ceramic.
J. Dent. Res. 1995, 74, 1591–1596.
55. Della Bona, A.; Anusavice, K.J.; Shen, C. Microtensile strength of composite bonded to
hot-pressed ceramics. J. Adhes. Dent. 2000, 2, 305–313.
56. Della Bona, A.; Anusavice, K.J.; Mecholsky, J.J. Failure analysis of resin composite bonded to
ceramic. Dent. Mater. 2003, 19, 693–699.
57. Della Bona, A.; Shen, C.; Anusavice, K.J. Work of adhesion of resin on treated lithia
disilicate-based ceramic. Dent. Mater. 2004, 20, 338–344.
58. Della Bona, A.; Anusavice, K.J.; Mecholsky, J.J. Apparent interfacial fracture toughness of
resin/ceramic systems. J. Dent. Res. 2006, 85, 1037–1041.
59. Lung, C.Y.; Matinlinna, J.P. Aspects of silane coupling agents and surface conditioning in dentistry:
An overview. Dent. Mater. 2012, 28, 467–477.
Materials 2015, 8 4989

60. Christensen, R.P.; Ploeger, B.J. A clinical comparison of zirconia, metal and alumina
fixed-prosthesis frameworks veneered with layered or pressed ceramic: A three-year report. J. Am.
Dent. Assoc. 2010, 141, 1317–1329.
61. Sailer, I.; Fehér, A.; Filser, F.; Gauckler, L.J.; Lüthy, H.; Hämmerle, C.H. Five-year clinical results
of zirconia frameworks for posterior fixed partial dentures. Int. J. Prosthodont. 2007, 20, 383–388.
62. Janda, R.; Roulet, J.F.; Wulf, M.; Tiller, H.J. A new adhesive technology for all-ceramics.
Dent. Mater. 2003, 19, 567–573.
63. Blatz, M.B.; Sadan, A.; Martin, J.; Lang, B. In vitro evaluation of shear bond strengths of resin to
densely-sintered high-purity zirconium-oxide ceramic after long-term storage and thermal cycling.
J. Prosthet. Dent. 2004, 91, 356–362.
64. Piwowarczyk, A.; Lauer, H.C.; Sorensen, J.A. The shear bond strength between luting cements
and zirconia ceramics after two pre-treatments. Oper. Dent. 2005, 30, 382–388.
65. Atsu, S.S.; Kilicarslan, M.A.; Kucukesmen, H.C.; Aka, P.S. Effect of zirconium-oxide ceramic
surface treatments on the bond strength to adhesive resin. J. Prosthet. Dent. 2006, 95, 430–436.
66. Lüthy, H.; Loeffel, O.; Hammerle, C.H. Effect of thermocycling on bond strength of luting cements
to zirconia ceramic. Dent. Mater. 2006, 22, 195–200.
67. Kumbuloglu, O.; Lassila, L.V.; User, A.; Vallittu, P.K. Bonding of resin composite luting cements
to zirconium oxide by two air-particle abrasion methods. Oper. Dent. 2006, 31, 248–255.
68. Blatz, M.B.; Chiche, G.; Holst, S.; Sadan, A. Influence of surface treatment and simulated aging
on bond strengths of luting agents to zirconia. Quintessence Int. 2007, 38, 745–753.
69. Wolfart, M.; Lehmann, F.; Wolfart, S.; Kern, M. Durability of the resin bond strength to zirconia
ceramic after using different surface conditioning methods. Dent. Mater. 2007, 23, 45–50.
70. Aboushelib, M.N.; Kleverlaan, C.J.; Feilzer, A.J. Selective infiltration-etching technique for a
strong and durable bond of resin cements to zirconia-based materials. J. Prosthet. Dent. 2007, 98,
379–388.
71. Yang, B.; Lange-Jansen, H.C.; Scharnberg, M.; Wolfart, S.; Ludwig, K.; Adelung, R.; Kern, M.
Influence of saliva contamination on zirconia ceramic bonding. Dent. Mater. 2008, 24, 508–513.
72. Aboushelib, M.N.; Matinlinna, J.P.; Salameh, Z.; Ounsi, H. Innovations in bonding to
zirconia-based materials: Part I. Dent. Mater. 2008, 24, 1268–1272.
73. Piascik, J.R.; Swift, E.J.; Thompson, J.Y.; Grego, S.; Stoner, B.R. Surface modification for
enhanced silanation of zirconia ceramics. Dent. Mater. 2009, 25, 1116–1121.
74. Cavalcanti, A.N.; Foxton, R.M.; Watson, T.F.; Oliveira, M.T.; Giannini, M.; Marchi, G.M. Bond
strength of resin cements to a zirconia ceramic with different surface treatments. Oper. Dent. 2009,
34, 280–287.
75. Heikkinen, T.T.; Lassila, L.V.J.; Martinlinna, J.P.; Vallittu, P.K. Thermocycling effects on resin
bond to silicatized and silanized zirconia. J. Adhes. Sci. Technol. 2009, 23, 1043–1051.
76. Aboushelib, M.N.; Mirmohamadi, H.; Matinlinna, J.P.; Kukk, E.; Ounsi, H.F.; Salameh, Z.
Innovations in bonding to zirconia-based materials. Part II: Focusing on chemical interactions.
Dent. Mater. 2009, 25, 989–993.
77. Oyagüe, R.C.; Monticelli, F.; Toledano, M.; Osorio, E.; Ferrari, M.; Osorio, R. Effect of water
aging on microtensile bond strength of dual-cured resin cements to pre-treated sintered zirconium-
oxide ceramics. Dent. Mater. 2009, 25, 392–399.
Materials 2015, 8 4990

78. Kitayama, S.; Nikaido, T.; Takahashi, R.; Zhu, L.; Ikeda, M.; Foxton, R.M.; Sadr, A.; Tagami, J.
Effect of primer treatment on bonding of resin cements to zirconia ceramic. Dent. Mater. 2010, 26,
426–432.
79. Magne, P.; Paranhos, M.P.; Burnett, L.H. New zirconia primer improves bond strength of
resin-based cements. Dent. Mater. 2010, 26, 345–352.
80. Qeblawi, D.M.; Muñoz, C.A.; Brewer, J.D.; Monaco, E.A. The effect of zirconia surface treatment
on flexural strength and shear bond strength to a resin cement. J. Prosthet. Dent. 2010, 103,
210–220.
81. Jevnikar, P.; Krnel, K.; Kocjan, A.; Funduk, N.; Kosmac, T. The effect of nano-structured alumina
coating on resin-bond strength to zirconia ceramics. Dent. Mater. 2010, 26, 688–696.
82. Attia, A.; Lehmann, F.; Kern, M. Influence of surface conditioning and cleaning methods on resin
bonding to zirconia ceramic. Dent. Mater. 2011, 27, 207–213.
83. Matinlinna, J.P.; Lassila, L.V. Enhanced resin-composite bonding to zirconia framework after
pretreatment with selected silane monomers. Dent. Mater. 2011, 27, 273–280.
84. Dias de Souza, G.M.; Thompson, V.P.; Braga, R.R. Effect of metal primers on microtensile bond
strength between zirconia and resin cements. J. Prosthet. Dent. 2011, 105, 296–303.
85. De Castro, H.L.; Corazza, P.H.; Paes-Júnior, T.de.A.; Della Bona, A. Influence of Y-TZP ceramic
treatment and different resin cements on bond strength to dentin. Dent. Mater. 2012, 28, 1191–1197.
86. Lung, C.Y.; Botelho, M.G.; Heinonen, M.; Matinlinna, J.P. Resin zirconia bonding promotion with
some novel coupling agents. Dent. Mater. 2012, 28, 863–872.
87. Piascik, J.R.; Swift, E.J.; Braswell, K.; Stoner, B.R. Surface fluorination of zirconia: Adhesive
bond strength comparison to commercial primers. Dent. Mater. 2012, 28, 604–608.
88. Chen, L.; Shen, H.; Suh, B.I. Effect of incorporating BisGMA resin on the bonding properties of
silane and zirconia primers. J. Prosthet. Dent. 2013, 110, 402–407.
89. Karimipour-Saryazdi, M.; Sadid-Zadeh, R.; Givan, D.; Burgess, J.O.; Ramp, L.C.; Liu, P.R.
Influence of surface treatment of yttrium-stabilized tetragonal zirconium oxides and cement type
on crown retention after artificial aging. J. Prosthet. Dent. 2014, 111, 395–403.
90. Bavbek, N.C.; Roulet, J.F.; Ozcan, M. Evaluation of microshear bond strength of orthodontic resin
cement to monolithic zirconium oxide as a function of surface conditioning method. J. Adhes.
Dent. 2014, 16, 473–480.
91. da Silva, E.M.; Miragaya, L.; Sabrosa, C.E.; Maia, L.C. Stability of the bond between two resin
cements and an yttria-stabilized zirconia ceramic after six months of aging in water. J. Prosthet.
Dent. 2014, 112, 568–575.
92. Oba, Y.; Koizumi, H.; Nakayama, D.; Ishii, T.; Akazawa, N.; Matsumura, H. Effect of silane and
phosphate primers on the adhesive performance of a tri-n-butylborane initiated luting agent bonded
to zirconia. Dent. Mater. J. 2014, 33, 226–232.
93. Pereira, L.L.; Campos, F.; Dal Piva, A.M.; Gondim, L.D.; Souza, R.O.; Özcan, M. Can application
of universal primers alone be a substitute for airborne-particle abrasion to improve adhesion of
resin cement to zirconia? J. Adhes. Dent. 2015, 17, 169–174.
94. Şanlı, S.; Çömlekoğlu, M.D.; Çömlekoğlu, E.; Sonugelen, M.; Pamir, T.; Darvell, B.W. Influence
of surface treatment on the resin-bonding of zirconia. Dent. Mater. 2015, 31, 657–668.
Materials 2015, 8 4991

95. Kim, G.H.; Park, S.W.; Lee, K.; Oh, G.J.; Lim, H.P. Shear bond strength between resin cement
and colored zirconia made with metal chlorides. J. Prosthet. Dent. 2015, 113, 603–608.
96. Abi-Rached, F.O.; Martins, S.B.; Almeida-Júnior, A.A.; Adabo, G.L.; Góes, M.S.; Fonseca, R.G.
Air abrasion before and/or after zirconia sintering: Surface characterization, flexural strength, and
resin cement bond strength. Oper. Dent. 2015, 40, E66–E75.
97. Oliveira-Ogliari, A.; Collares, F.M.; Feitosa, V.P.; Sauro, S.; Ogliari, F.A.; Moraes, R.R. Methacrylate
bonding to zirconia by in situ silica nanoparticle surface deposition. Dent. Mater. 2015, 31, 68–76.
98. Lung, C.Y.; Liu, D.; Matinlinna, J.P. Silica coating of zirconia by silicon nitride hydrolysis on
adhesion promotion of resin to zirconia. Mater. Sci. Eng. C Mater. Biol. Appl. 2015, 46, 103–110.
99. Sciasci, P.; Abi-Rached, F.O.; Adabo, G.L.; Baldissara, P.; Fonseca, R.G. Effect of surface
treatments on the shear bond strength of luting cements to Y-TZP ceramic. J. Prosthet. Dent. 2015,
113, 212–219.
100. Qeblawi, D.M.; Campillo-Funollet, M.; Muñoz, C.A. In vitro shear bond strength of two
self-adhesive resin cements to zirconia. J. Prosthet. Dent. 2015, 113, 122–127.
101. Yi, Y.A.; Ahn, J.S.; Park, Y.J.; Jun, S.H.; Lee, I.B.; Cho, B.H.; Son, H.H.; Seo, D.G. The effect of
sandblasting and different primers on shear bond strength between yttria-tetragonal zirconia
polycrystal ceramic and a self-adhesive resin cement. Oper. Dent. 2015, 40, 63–71.
102. Kim, J.H.; Chae, S.Y.; Lee, Y.; Han, G.J.; Cho, B.H. Effects of multipurpose, universal adhesives
on resin bonding to zirconia ceramic. Oper. Dent. 2015, 40, 55–62.
103. Druck, C.C.; Pozzobon, J.L.; Callegari, G.L.; Dorneles, L.S.; Valandro, L.F. Adhesion to Y-TZP
ceramic: Study of silica nanofilm coating on the surface of Y-TZP. J. Biomed. Mater. Res. B
Appl. Biomater. 2015, 103, 143–150.
104. Borba, M.; de Araújo, M.D.; Fukushima, K.A.; Yoshimura, H.N.; Cesar, P.F.; Griggs, J.A.; Della
Bona, A. Effect of the microstructure on the lifetime of dental ceramics. Dent. Mater. 2011,
27, 710–721.
105. Kelly, J.R. Dental ceramics: Current thinking and trends. Dent. Clin. N. Am. 2004, 48, 513–530.
106. Kelly, J.R.; Denry, I. Stabilized zirconia as a structural ceramic: An overview. Dent. Mater. 2008,
24, 289–298.
107. Rekow, E.D.; Harsono, M.; Janal, M.; Thompson, V.P.; Zhang, G. Factorial analysis of variables
influencing stress in all-ceramic crowns. Dent. Mater. 2006, 22, 125–132.
108. Kelly, J.R.; Benetti, P.; Rungruanganunt, P.; Bona, A.D. The slippery slope: Critical perspectives
on in vitro research methodologies. Dent. Mater. 2012, 28, 41–51.
109. Quinn, G.D. Fractography of Ceramics and Glasses; National Institute of Standards and Technology
(NIST): Gaithersburg, MD, USA, 2007.
110. Borba, M.; de Araújo, M.D.; de Lima, E.; Yoshimura, H.N.; Cesar, P.F.; Griggs, J.A.; Della Bona, A.
Flexural strength and failure modes of layered ceramic structures. Dent. Mater. 2011, 27, 1259–1266.
111. Della Bona, A.; Mecholsky, J.J.; Anusavice, K.J. Fracture behavior of lithia disilicate- and
leucite-based ceramics. Dent. Mater. 2004, 20, 956–962.

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